ECG Sibanor Health Center, the Republic of the Gambia

I gained increased competence in assessing and managing patients with advanced HIV. Sibanor Health Center is the third largest facility for HIV care in The Gambia, and in 2023 provided 3,411 clinic consultations alongside a home-based outreach programme. My role as a doctor within the HIV service involved reviewing the unwell and unstable patients attending  review appointments. Often patients required admission to the ward for treatment of AIDS-related conditions such as investigation and initiation of TB treatment.  Other common diagnoses included severe malnutrition, HIV/TB drug-related complications, oesophageal candidiasis and other fungal skin infections, Kaposi’s sarcoma and severe herpes infection.

Whilst we had some facilities to care for patients with palliative care needs, patients with end- stage HIV and TB were transferred to our nearest government hospital due to the complexity of end-stage care needs. I observed the cultural challenges of changing treatment goals from curative treatment to symptom management. For example, patients and families often perceived that withdrawing active treatment, even in a patient’s best interest, was a form of curse or an action that foreshadowed death. In addition to onward referral for palliative care needs, we would also refer complex cases of SLE, acute heart failure secondary to rheumatic heart disease, post-partum cardiomyopathy, sickle-cell crisis and liver abscess. 

Whilst I was working in The Gambia, temperatures were regularly over 40 degrees, and exceeded the usual average for this time of year. The World Service recently reported on the African heatwave in March and April which has affected large parts of West Africa, namely Senegal, Mali and the Sahel region (extending into The Gambia).   This has been attributed, in part, to anthropogenic climate change.  In the clinic we saw some of the direct impact that heat stress has on health outcomes. Furthermore, no air conditioning or fans were available due to costs and power shortages. We treated many patients with severe dehydration, heat exhaustion and respiratory compromise as a direct result of these high temperatures. Droughts have also been recorded, with crop yields impacted, and we have seen more malnutrition attendances in our clinic which were attributed by some to increased food prices linked to food shortages.

Professional Development – Leadership, Problem Solving and System Learning

The role, responsibilities and lifestyle of the rural doctor here are far more varied and challenging than I expected. Although I was volunteering as a junior doctor and under supervision from senior colleagues, my work in the clinic involved helping to coordinate drug stocks, managing water pump failures, teaching clinical skills at the weekly staff meeting, and updating our clinic treatment manual based on evidence-based best practice for low resource settings. The WHO, MSF and UpToDate were valuable resources for clinical treatment in low-income settings, though clinic-level updates to the manual also necessarily considered the (lack of) availability of specific medicines in The Gambia and which medicines could be used safely in the absence of blood test monitoring. Whilst HIV/TB medicines and nutritional supplements are provided by the government, all other medicines are bought through the city pharmacy outlets and the IDA Foundation.  In these contexts, doctors must adapt clinical best practice in line with resource availability and experiential insights to respond quickly and thoroughly to case presentations. Doctors also need to have a whole systems knowledge of the clinical settings they work in, as repair services for basic services may not be readily available or affordable.

Furthermore, this experience has taught me more about the necessity of compassionate and shared decision making where healthcare is a costed service. The clinic has an established ‘poor patient fund’ which is used to subsidise treatment costs with patients paying what they can. The fund receives income from church sponsors and international donors. Whilst this subsidises costs for many of patients, healthcare being a paid-for service in a low-income context means we had to carefully consider treatment decisions, not only on clinical efficacy but also on the cost implication of final treatment for the patient. For example, we saw many patients with advanced cancers for whom referral to the city hospitals for review in clinic would be the next step for clinical treatment but who were unable to afford travel or the government clinic costs. In these cases, the clinic provided symptom relief and practical management strategies where possible.  Without this fund many people would be unable to access any healthcare. Whilst some question the sustainability of this fund, I believe it plays an essential role in enabling health coverage for all in the community.

This experience has also shown me how even the small costs for essential medicines can be catastrophic for families, often pushing them into extreme poverty.  Witnessing the positive impact of cost sharing for health has made me determined to advocate for universal health coverage. The voices of local communities who experience the effects of ‘fee for service’ healthcare have not been heard by policy makers, and much stronger national and regional advocacy is needed. I believe Royal Colleges and members can speak powerfully to this important area.

One of the steepest learning curves for me was understanding and working within the systems of both the Sibanor clinic and the wider health system, such as the triage processes, patient flow and onward referral. A full understanding and integration of working in this system requires an appreciation of both Gambian culture and the different, highly contextual, barriers to health access. The clearest example of this is reflected in the barriers to HIV testing and treatment which are a result of significant ongoing stigma. To respond to this, the clinic ensures that records and conversations about HIV status are strictly confidential, and every effort is made to keep this understanding between the patient and health provider. Stigma and non-disclosure to partners is recognised by staff as the biggest challenge in the prevention of HIV transmission in The Gambia. However, through outreach programmes and counselling, the clinic is working effectively to break down barriers to testing and treatment and has seen some positive results with respect to medication compliancy.

As a result of volunteering at Sibanor I have been invited to return to Gambia for a one-month voluntary project working at the MRC Gambia. I am very grateful for this onward opportunity, which will allow me to bring together my interest in researching best practice with clinical responsibilities and skills learned at Sibanor.

Impact on the Clinic and Shared Value

During my short time at Sibanor, I was fortunate to be able to contribute to the treatment manual which is used daily by the doctors and nurse treaters The areas I reviewed include TB preventative-therapy guidelines, antenatal care, malaria prophylaxis, and antibiotic guidelines for commonly diagnosed conditions (LRTI, neonatal sepsis, and acute bacterial gastroenteritis).

I also engaged in teaching clinical skills for the nursing and medical team. This involved teaching at the formal weekly staff meetings, as well as informal practical teaching for nurses. I mentored the nurses in child growth assessment and identification of malnutrition, and I also learned from the nurses with their immense clinical expertise and experience. I hope, in a small way, to have supported their professional development and their confidence in applying their expertise to a wider variety of clinical roles. 

As a rural health clinic, there is only one senior doctor on-call night and day, often for weeks at a time. The senior doctors who I worked with at Sibanor expressed gratitude in having an extra person to reduce workload during daytime hours and to share the responsibility of on-call duties. I was able to share some insights and knowledge gained through my experience as a junior doctor in the UK, including on antibiotic stewardship, and the feedback was that this was appreciated by both nursing and medical staff in the clinic. I was most impressed by the clinical competencies of nurses and senior doctors who need to be able to master a range of clinical skills.

Final Reflections

I will return to UK practice with a greater appreciation for the value of universal health coverage, global health challenges including sustainability of clinical practices and funding models, the impacts of climate change on health outcomes now, and the issues resulting from our choices as individuals and as an organisation (e.g. our NHS carbon footprint). I also believe I have developed a richer understanding of the nature of disease manifestations and appreciation of clinical examination in The Gambia. As a result of working at Sibanor, I plan to sustain connections to this clinic for many years to come and to advocate for the work and funding of the clinic where I can.  Through this report, and my honest reflections of this opportunity, I hope that the RCPE also recognises the value of these travel opportunities and will continue to sponsor other doctors in their contributions to global health partnerships.

Dr Catriona Grant, April 2024